The Risk of Atherosclerotic Cardiovascular Disease among Hyperlipidaemia Patients and Appropriateness of Statin Therapy
Maharani F. Iskandar, Nurmainah Nurmainah, Ressi Susanti Department of Pharmacy, Faculty of Medicine, Tanjungpura University,
Pontianak, West Kalimantan, Indonesia
Abstract
Patients with hyperlipidaemia is at increased risk of developing atherosclerotic cardiovas- cular disease (ASCVD). The use of appropriate statin therapy is important to obtain opti- mal health outcomes. However, there was limited information regarding the risk of ASCVD among Indonesian hyperlipidaemia population and the appropriateness of statin therapy given to these patients. This study aimed to assess the ASCVD risks among the patients and evaluate the use of statin therapy at hospitalized hyperlidaemia patients. This cross sectional study used medical records as data source. This study was conducted at one hospital in Pontianak, Indonesia during Januari-June 2017. We included 50 subjects. The 10-year risk of ASCVD was assessed using ASCVD pooled cohort risk assessment equation (PCRAE).
The results showed that 66% of the included subjects had a relatively high risk of develop- ing ASCVD. Subjects with high risk of ASCVD received inappropriate statin therapy. High intensity statin should be given to these patients. In conclusion, large proportion of the sub- jects were at high risk of developing ASCVD. Nevertheless, inappropriate statin therapy were given to these patients. Improvement in medication practice should be done to prevent complication and increase quality of health outcomes.
Keywords: ASCVD, dyslipidemia, statin
Introduction
Hyperlipidaemia is characterized by elevated concentrations of any or all lipids in the plasma. It is one of the risk factors of atherosclerotic cardiovascular disease (ASCVD), including coronary heart disease (CHF), stroke, and peripheral arterial disease. It is one of the leading cause of death worldwide.1,2
American Heart Association (AHA) in 2013, recommended statin as the primary drug of choice for hyperlipidaemia patients. There are four groups that are most likely to obtain the benefits of using statin, including patients with ASCVD, patients with LDL ≥ 190 mg/
dl, patients with diabetes mellitus (40-75 years), with LDL level of 70-189 mg/dl, and
Corresponding author: Maharani F. Iskandar. Department of Pharmacy, Faculty of Medicine, Tanjungpura Univer- sity, Pontianak, West Kalimantan, Indonesia. Email:maharani9583@gmail.com
Received: 31 March 2018. Revised: 11 April 2018. Published: 23 April 2018.
patients without diabetes (40-75 years) with an estimated 10-year ASCVD risk ≥ 7.5%.3,4 Patients who have clinical evidence of ASCVD and patients with LDL ≥ 190 mg/
dl should be given high intensity statin.
Patients with low risk of developing ASCVD should consume moderate intensity statin.
A 10-year risk of ASCVD could be assessed periodically using ASCVD pooled cohort risk assessment equation (PCRAE). 5
However, there was limited information regarding the risk of ASCVD among Indonesian hyperlipidaemia population and the appropriateness of statin therapy given to these patients. This study aimed to assess the ASCVD risks among the hospitalized hyperlipidaemia patients and evaluate the use of statin therapy.
Methods
This cross sectional study used medical records as data source. This study was conducted at one hospital in Pontianak, Indonesia during Januari-June 2017. The inclusion criteria were hospitalized-hyperlipidaemia patients, aged >18 years. We excluded patients with pre-existing cardiovascular disease.
Informed consent was not required because this observational study did not change the intervention and outcome of the patients.
From each medical record, we extracted data regarding demographic characteristics, diabetes status, smoking status, and various clinical outcomes, including total cholesterol, HDL cholesterol, LDL cholesterol, blood pressure, and whether or not patients receiving antihypertensive treatment (if systolic blood pressure > 120 mmHg).
The data obtained were assessed using PCRAE to estimate the 10-year risk of ASCVD among patients. Descriptive analysis was used to evaluate the data.
Results dan Discussion
We included 50 subjects who met the inclusion criteria. Characteristics of the subjects is presented in Table 1. Majority of the patients were female (62%) and aged >50 years (84%). Most patients (70%) suffered from diabetes and about 62% did not have smoking habits.
In contrast to previous study, male have higher risk of having exceeded lipid level than female.Female have estrogen hormone that prevents lipid profile abnormalities. This protective nature will disappear after women experience menopause. Decreased estrogen levels lead to decreased LDL catabolism and hepatic HDL removal, which can lead to the risk of atherosclerosis.6
Age is one of the risk factors that play a role in the incidence of cardiovascular disease.
The risk of mortality will increase with age. The aging process naturally causes the blood vessels to be more susceptible to atherosclerosis. Inflammatory cells, endothelial cells, and smooth muscle cells of the blood vessels in the elderly differ from that of younger adults. Aging causes changes in the cell proliferation, apoptotic processes, and DNA repairment. The layers of intima and vascular media in the aging process continue to experience remodeling due to increased collagen deposition and elastin degeneration, so that blood vessels lose their elasticity and become stiff.7
Cholesterol levels affect the incidence of cardiovascular disease. Based on the results of this study, the percentage of hyperlipidemic patients (patients who had total cholesterol
> 200 mg /dl) was 94%. High cholesterol levels can lead to increased free fatty acids, which can lead to damage to beta cells of the pancreas so that the risk of diabetes mellitus could increase. Previous study found that
people who had high cholesterol levels were 13.45 times more likely to suffer from type 2 diabetes mellitus than people who have normal cholesterol levels. Diabetes mellitus is one of the risk factors that can cause atherosclerosis.8
LDL cholesterol levels play a major role in the incidence of cardiovascular disease. Based on the results of this study, 96% subjects had LDL level > 100 mg.dl. Increased levels of LDL cholesterol is a strong predictor of the risk of cardiovascular events. LDL in the body is used in the repairment of cell
membrane and in the production of steroid hormone and bile salts, but if the amount of serum LDL is excessive, it could cause hypercholesterolemia which could result in atherosclerosis.9
Increase in HDL level is important for cardiovascular health. Based on the results of this study, half (56%) of the patients had HDL value < 55 mg/dl. Decreasing HDL cholesterol levels in the blood will increase the risk of atherosclerosis. Endothelium dysfunction caused by repeated or persistent exposure will cause injury to the artery Table 1. Characteristics of participants
Characteristics n=50
Number Percentage (%)
Sex Male
Female 19
31 38
62 Age 40-50 years
> 50 years 8
42 16
84 Cholesterol level
< 200 mg/dL
> 200 mg/dL 3
47 6
94 LDL level
< 100 mg/dl
> 100 mg/dl 2
48 4
96 HDL level
< 55 mg/dl
> 55 mg/dl 28
22 56
44 Diabetes mellitus
Yes
No 35
15 70
30 Consumed anti-hypertensive drugs
Yes
No 21
29 42
58 Blood pressure
< 130 mmHg
> 130 mmHg 22
28 44
56 Smoking status
Yes
No 19
31 38
62
wall.10,11
We found that patients who were at high risk of developing ASCVD receive inappropriate statin treatment (Table 2). They should be given high-intensity statin which include atorvastatin 80 mg or rosuvastatin 20-40 mg.
Moderate intensity statin includes atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, pravastatin 40-80 mg, lovastatin 40 mg, fluvastatin XL 80, and pitavastatin 2-4 mg.4
Conclusion
In conclusion, large proportion of the subjects were at high risk of developing ASCVD.
Nevertheless, inappropriate statin therapy were given to these patients. Improvement in medication practice should be done to prevent complication and increase quality of health outcomes.
Acknowledgements
The author would like to thank all medical staff at Sultan Syarif Mohamad Alkadrie General Hospital, Pontianak and counselor at Tanjungpura University.
Funding None.
Conflicts of Interest None declared.
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Table 2. Assessment of statin therapy Patients group Recommended
Statin Statin
Prescibed Information Patients with class III hyperlipidae-
mia with ASCVD Risk < 7.5 % Moderate intensity
statin Simvastatin 20 mg /
Atorvastatin 20 mg Appropriate Patients with class III hyperlipidae-
mia with ASCVD Risk > 7.5 %. High intensity statin Simvastatin 20 mg/
Atorvastatin 20 mg Not appropriate Patients with class IV hyperlipidae-
mia without diabetes with ASCVD Risk < 7.5 %.
Moderate intensity
statin Simvastatin 20 mg /
Atorvastatin 20 mg Appropriate Patients with class IV hyperlipidae-
mia without diabetes with ASCVD Risk > 7.5 %.
High intensity statin Simvastatin 20 mg/
Atorvastatin 20 mg Not appropriate
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